Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Declaration *

I declare that: • I am over age 18. • I am not an undischarged bankrupt. • I have not entered into a composition or arrangement with creditors which includes an individual voluntary arrangement (IVA), and am not currently on the Insolvency Service Register. • I have not previously been removed from trusteeship of a charity by a Court or the Charity Commission. • I am not under a disqualification order under the Company Directors' Disqualification Act 1986. • I have not been convicted of an offence involving deception or dishonesty (unless the conviction is spent). • I am, in the light of the above, not disqualified by the Charities Act 2011 (sections 178 to 180) from acting as a charity trustee. I declare that the information I have given in support of my application is, to the best of my knowledge and belief, true and complete. I understand that if it is subsequently discovered that any statement is false or misleading, or that I have withheld relevant information my application may be disqualified or, if I have already been appointed that appointment may be revoked.

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